Long-term effect of triamcinolone acetonide in the treatment of upper lid retraction with thyroid associated ophthalmopathy

Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future?

Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.

Observations on the Efficacy of Two Methods for the Treatment of Upper Eyelid Retraction in Thyroid-Associated Ophthalmopathy

Objective

To observe the clinical efficacy of periocular injection of triamcinolone acetonide (TA) and subpalpebral injection of botulinum toxin type A (BTXA) for the treatment of thyroid-associated ophthalmopathy (TAO) with mild unilateral upper eyelid retraction.

Method

This was a prospective randomized controlled study. A total of 68 cases of stable thyroid-associated ophthalmopathy with mild upper eyelid retraction were collected at Hankou Aier Eye Hospital from Jan. 2015 to Dec. 2018 and randomly divided into two groups. Group A contained 33 patients who were administered TA by periocular injection once every 3 weeks for a total of 3 times. Group B contained 35 patients who were given a single subpalpebral administration of BTXA. The efficacy in the two groups was observed.

Results

Compared with the two groups, the effective rate in both groups was 100% at 1 week and 1 month after treatment. The effective rate of Group A remained 100% at 3 months after treatment, and that of Group B decreased to 88.6%. At 1 week after treatment, the degree of correction in Group B was greater than that in Group A (p < 0.001). At 1 month after treatment, it was not significantly different between the two groups (p > >>0.05). At 3 months after treatment, it was less in Group B than in Group A (p < 0.001). In Group A, there was one case of transient amaurosis, two cases of periorbital hemorrhage and swelling, and one mild case of sunken eyes. In Group B, four cases experienced recurrence after 3 months.

Conclusion

Periocular injection of TA and subpalpebral injection of BTXA offer definite therapeutic efficacy for mild upper eyelid retraction associated with thyroid disease. The former has a long treatment period, large procedural risks, and stable efficacy. The latter is a simple procedure with a short treatment period but can easily recur.

Clinical features and clinical course of thyroid-associated ophthalmopathy: a case series of 3620 Chinese cases

OBJECTIVES

To determine the clinical features and course of thyroid-associated ophthalmopathy (TAO) in a large sample of Chinese patients.

DESIGN AND METHODS

We retrospectively identified a cohort of consecutive patients diagnosed with TAO at the West China Hospital from October 1, 2009 to October 1, 2019. We analysed clinical data from 3620 patients, including demographic data, clinical manifestations, ophthalmology examinations, and prognosis.

RESULTS

TAO most frequently occurred with hyperthyroidism, with most patients developing TAO after thyroid disease (TD). The TAO phenotype was asymmetric in 375 (50.7%) euthyroid patients, 25 (27.8%) hypothyroid patients, and 314 (12.1%) hyperthyroid patients (p < 0.0001). The most frequent symptom was lid lag and the most commonly involved extraocular muscle was the inferior rectus. Severity assessment (NOSPECS score) and clinical activity assessment (Clinical Activity Scores, CAS) differed significantly between male and female patients (P < 0.000). The majority (88.8%) of patients had clinically inactive TAO, and only 3.2% of cases were sight-threatening. Regarding the clinical process, 75.5% of patients had an active phase time less than 12 months and 2.1% showed complete remission.

CONCLUSIONS

TAO most commonly develops in females and is closely related to hyperthyroidism. Euthyroid TAO often has an asymmetric clinical phenotype. CAS combined with magnetic resonance imaging can improve the detection of TAO. NOSPECS scores should be slightly refined regarding the criteria for corneal involvement. Clinical management of TAO should be individualized according to CAS or NOSPECS assessments and a multidisciplinary approach is paramount. A minority of patients showed complete remission.